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Laparoscopy
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Farr Nezhat, Carmel Cohen, Nimesh P. Nagarsheth
Following the “medial-to-lateral” approach, the vascular pedicles are identified early in the procedure and are separated from vital structures such as the duodenum before division of the lateral peritoneal attachments. The vessels are transected with margins allowing for complete cytoreduction of tumor involving the bowel and mesentery (Figure 26.33). Keeping the bowel attached to the lateral abdominal wall during this part of the procedure allows for counter traction and easier mobilization. Once the vessels have been transected, the lesser sac is entered by dividing the gastrocolic ligament and the hepatocolic ligament (Figure 26.34). The lateral attachments are divided with sharp dissection using the unipolar cautery device, and the bowel is easily mobilized and exteriorized. It is important to note that a lateral-to-medial approach is equally as effective, and preference is based on surgeon expertise and preference. Although no large prospective randomized controlled studies have compared laparoscopic bowel resection versus open bowel resection in the management of gynecologic cancers, extrapolating from the colorectal surgery literature suggests that outcomes would be equivalent.
Techniques of adrenalectomy
Published in Demetrius Pertsemlidis, William B. Inabnet III, Michel Gagner, Endocrine Surgery, 2017
Minerva Angelica Romero Arenas, Ashley Stewart, Nancy D. Perrier
The anterior approach is the most common open approach and can be done via a variety of abdominal incisions. The preferred approach at our institution is the subcostal laparotomy, which can be extended to a chevron incision when greater exposure is needed or for bilateral disease. Another incision option for very bulky tumors extending into multiple surrounding organs or the diaphragm is the thoracoabdominal incision, also known as the Makuuchi incision. This incision begins just below the tip of the scapulae and is extended in an oblique fashion to the midline of the abdomen. This incision is utilized for many different procedures, as it provides extensive exposure of retroperitoneal organs and facilitates en bloc resection of tumors difficult to access through an abdominal incision [13–15]. There is debate, however, that this approach is associated with more morbidity postoperatively [14]. Patient positioning is of the utmost importance and facilitates an easier operation with better exposure. The patient is supine with arms extended on either side with arm boards. A bump is then placed under the side planned for resection, such that the patient is extended maximally at the inferior costal margin. The bump, best made by rolled linens, should extend from the tip of the scapula to the top of the buttocks. The leg of the elevated side is flexed at the knee and rotated slightly over midline, while the opposite leg is straight and in anatomic position. Proper attention to pressure points in this position is always recommended. This patient positioning and abdominal incision provides excellent access to both adrenals and surrounding organs. Access to the right gland begins with mobilization of the hepatic flexure of the colon and partial “kocherization” of the curve of the duodenum to better visualize the IVC and take off of the right adrenal vein. For tumors that extend beyond Morrison’s pouch and into the retrohepatic space, increased mobilization of the right lobe of the liver may be necessary for a safe en bloc resection of the tumor. This is achieved by division of the right triangular ligament of the liver, allowing for anteromedial retraction of the right lobe of the liver. Care should be taken to avoid injury to the right hepatic vein and any accessory inferior phrenic veins with this retraction on the liver. This maneuver can also cause compression of the IVC and decreased venous return; therefore, communication with the anesthesia team is imperative during this portion of the case. Incision into the parietal peritoneum and the lateral aspect of the hepatocolic ligament can then be made and the kidney retracted caudally, exposing the right adrenal.
A minimally invasive treatment of an asymptomatic case of mesh erosion into the caecum after total extraperitoneal inguinal hernia repair
Published in Acta Chirurgica Belgica, 2019
Gert Mulleners, Frederick Olivier, Mohamed Abasbassi
An exploratory laparoscopy was performed using a 12 mm supra-umbilical port, that revealed adhesion of the caecum anteriorly to the right groin (Figure 2(b)). The clips that were previously used for peritoneal closure were no longer visible. Three additional 5 mm ports were inserted under direct vision in the left lower quadrant, the suprapubic region and the left upper quadrant. The ileum was flipped over from the pelvis to the right upper quadrant to expose the ileocolic pedicle. A retromesenteric plane was entered posterior to the ileocolic pedicle. The retromesenteric plane was further developed by blunt dissection laterally and in a cephalad direction along the duodenum. Subsequently, the hepatic flexure was mobilised by incising the hepatocolic ligament from medial to lateral to establish a connection to the previously freed retroperitoneal plane. The right colon was released from its lateral peritoneal attachments by dividing the white line of Toldt. This allowed for the complete mobilisation of the right colon and a straightforward attachment of the caecum to the mesh (Figure 2(c)). The mesh was then cut by sharp dissection, leaving a defect of 2.5 by 2 cm. A 3 cm midline incision was made by extending the supra-umbilical port cephalad. The mobilised right colon was exteriorised after insertion of an Alexis® wound protector (Figure 2(d)). Only the resection of the base of the caecum and appendix was required as the ileocecal valve was not affected by the inflammatory process. A stapled resection was performed after opening the caecum and ensuring complete removal of the mesh. After returning the colon and re-insufflating the abdomen, the lateral umbilical fold was sutured over the peritoneal defect to cover the remainder of the mesh.